We need a complete overhauling of our thinking about health sector

The ongoing Covid-19 pandemic crisis has brought to the front the importance of 'health' and  the 'health sector', their unequivocally critical role in the survival of the modern-day human and economic life – not just in Bangladesh but also in the world as a whole. Here in Bangladesh, we have observed how poor our health service is, how inadequate our health sector infrastructure is and how fragile is its management in providing health service to both Covid-19 as well as non-Covid-19 patients.

We have to consider two things here. Is the health sector synonymous with the health ministry? Evidently it is not. If you consider the WHO definition of 'health', you will see, 'health' is not just merely absence of diseases and infirmity, but it's also a complete state of mental and social wellbeing of people. I want to emphasize on social wellbeing. 

Also, 'healthcare' is divided into three distinct but, of course, interdependent and interrelated cares: curative, preventive and promotional.

Safe drinking water, sanitary latrine, basic hygiene are being highlighted during the Covid-19 pandemic - all these fall under the purview of the local government ministry.

Health also covers the wellbeing of mothers and children; preventive and promotional aspects of this area are not supervised by the health ministry. The women and children affairs' ministry is there to look after them. Under the social wellbeing of health service, the government has to look after the poor, the destitute, the handicapped, and the street children, which are to be covered by the social welfare ministry.

We hear about the importance of diet, of Vitamin D, Vitamin A, nutritious foods, food habits—which authority is there to deal with those? It is the food ministry. The agriculture ministry is also involved here. Health is also very much related to the environment.

When it is the issue of promoting ideas, then we see the role of the education ministry as well. So preventive and promotional aspects of health services are not under the health ministry alone. There are several other ministries involved. The health ministry deals merely with the curative aspect of healthcare and additionally, medical education. To maximise the results of the efforts put in health care, we need a well-developed well-functioning inter-ministerial committee.

So, we have to look into the health ministry budget and health sector budget separately. If you consider it that way, you will find that the health sector allocation in Bangladesh is not just 1% (of the Gross Domestic Product). It will be above 3% if all other relevant aspects of healthcare are taken together in consideration which we often miss while talking about the health budget. When we talk about health care, we have to cover social wellbeing, mental wellbeing in addition to physical well-being. We will also have to cover preventive and promotive healthcare as well. The health sector involves a much broader area than what we see the health ministry covering.

There is a popular demand for raising the health sector budget to 2% or 4% of the GDP. In most cases, these demands are a misunderstanding about what 'health' and the 'health sector' stand for. Moreover, budget allocation to a particular ministry/division depends on the government's revenue earnings, borrowing capability, and also, it hinges upon the resource utilisation capacity of the respective ministry/division. The government always functions under budget constraints. For the last 20 years, our revenue earnings are hovering around 10% of our GDP and social expenditure is around 16%. The government has other priorities as well. We have to determine our priority. We cannot ensure social wellbeing without graduating the poor to a higher income level, without improving the agriculture sector, without developing the education sector. We cannot ignore the environmental priority as well.

According to standard definition, the health sector represents the whole social infrastructure, which will form the social capital and that will increase growth and people's welfare. Investments only in physical infrastructure will not automatically bring people's welfare. To sustain growth, we need to invest more in social capital to have educated, well-nourished, healthy human beings. So, in my view, our priority should be on investing more in social sectors, which, as per WHO definition, is synonymous with the broader concept of the health sector.

Social welfare should be our first priority, which means that we must elevate people from poverty, we have to ensure food security, impart them with quality education and skills training, we need to ensure their good health—which largely depends on preventive and promotive healthcare. If we cannot ensure good health of a juvenile girl, you cannot expect a healthy mother, healthy posterity and a developed happy prosperous Bangladesh.

The Covid-19 outbreak has shown us that the health sector should be synonymous with our social sector. A well managed health sector will provide us with a healthy economy. If we want to sustain growth and make development welfare-oriented, we need to invest more in social health which inter-alia incorporates the public health and  nutrition level of our people.

If we look at the allocation of the health ministry,  it is just about 1% of GDP. Is their budget inadequate? Yes, it is. This allocation is insufficient. But we must see whether it has the capacity to utilize this much money, even if we set  aside the question of efficient and effective use for the time being.   If we look at the resource utilisation pattern of the health ministry of the last two decades, on an average 10 % of their allocations, amounting to around Tk1,000 crore remained unutilised.

Let us now consider the definition of curative healthcare which has primarily three tiers—primary, secondary and tertiary. Community, union health centres are providing primary care, the upazila health complex is providing both primary and secondary health care, district hospitals provide secondary health care and medical colleges offer tertiary healthcare.  

If you think beyond Covid-19, you will see we have made notable progress in the health sector, especially in achieving millennium development goals in child and maternal mortality and life expectancy. We actually fared well in the region. I can remember a 2012 article of The Economist that stated that Bangladesh's rapid progress in these areas has not been witnessed anywhere in the world before. Praise by the international community of our success in EPI, in malaria and tuberculosis control is well-documented. This achievement came through cooperative functioning  among the government, development partners, NGOs and local communities.

Of the three tiers of curative healthcare, primary health care contributes the maximum public good and this tier deserves allocations of key health sector resources. Tertiary level healthcare is more a private good than public good. But creating a national research fund for physical and medical sciences is of utmost national priority to move the country forward to ensure and sustain our national health.

In terms of manpower, the health ministry is the second largest among the ministries. Why is it failing to ensure basic healthcare for the people? Because it is giving priorities to promotion and posting of its human resources and spending most of its time in scrambling project resources. Doctors, being a relatively organised profession, somehow could influence the policymaking of the health ministry and more or less all developments in the curative health sector are doctors-centric. There is one doctor for 6,000 people in Bangladesh while the international norm is 1:1000, but the ratio of nurses and other medical professionals is very low, in fact at a dismal low. In a standard health structure, doctor-nurse-health technician should be 1:3:5, which  is 1:0.5:0.25 in Bangladesh.

At the cost of sacrificing quality, we are establishing more institutions for doctors both in the private and public sector but we did not do enough to produce skilled nurses and did almost nothing to produce health technologists, paramedics and other related manpower. Till now, we could not introduce a referral system. Little has been done on ensuring ethical practices in private hospitals and medical colleges. Can we think of creating a cadre of medical managers and legislating a law to ensure medical ethics? As we are observing hospitals refusing patients on flimsy ground and an ailing patient is being taken off the ventilator despite the objections of his children, this is the high time to go for these. Last but not least, we must think about introducing health insurance if we really want to ensure a better healthcare for all.

Despite being a poor economy, we have good healthcare infrastructure, but we could not ensure quality service, which is to a large extent a policy issue. Hospitals in the USA also faced shortages of PPEs and masks during this pandemic crisis. So. It's more an issue of proper policy planning and implementing the policy in a well-structured, well managed system. The health policy framed in 2011 was not a policy in the true sense of the term as it lacked a prudent implementation plan. Even, mental health and social wellbeing were not given due importance in the policy.

The Covid-19 outbreak has brought to the front how important mental health is in the overall public health system. The pandemic has also shown the health system does not comprise of doctors and nurses only, it involves police, biochemists, pharmacists, genetic engineers and so on. Health is a cross-sectional sector involving many areas and issues.

It is time to reformulate the health policy with appropriate stake-holders' consultations.  If a public policy specialist, a psychologist and a sociologist along with other relevant professionals were incorporated in the committee, then a more comprehensive and pragmatic health policy would have been framed.

Why are we good at natural disaster management? We faced a series of disasters, suffered huge losses of life and property, and over the years developed a standard operating procedure (SOP) for disaster management. We need to have such an SOP for the healthcare sector, we need to remodel the health policy incorporating a detailed planning and management structure for pandemic management. The health ministry must decentralise its works within the ministry and beyond, defining the role of the community, NGOs, private healthcare providers from the grassroots up to the centre. A cooperative model will result in a more socially desired outcome.

Mohammad Tareque is the Managing Director, Board Of Trustees and Director, of Bangladesh Institute of Governance and Management (BIGM)